Simon Allard

The course of depression in recent onset rheumatoid arthritis: the predictive role of disability, illness perceptions, pain and coping.

BACKGROUND This study aimed to investigate the course of depression for patients with recently diagnosed rheumatoid arthritis (RA) and to investigate predictors of depression. METHODS Twenty-two patients with a history of recently diagnosed RA of less than 2 years were assessed on a variety of clinical outcome and process measures on six assessment occasions over a 21-month period. These 22 patients constituted the control group of a controlled trial and received standard outpatient clinic treatment during follow-up. RESULTS Patients became significantly more depressed over time. A set of five factors were found to consistently predict depression at the following assessment. These were initial level of depression, disability, pain, beliefs about the consequences of arthritis and coping strategies. CONCLUSIONS The results confirm the importance of psychological factors in early RA and their relative independence from physical findings. This is the first study to document the importance of illness perceptions in recent onset RA.

A blind, randomized, controlled trial of cognitive-behavioural intervention for patients with recent onset rheumatoid arthritis: preventing psychological and physical morbidity

&NA; This study examined the efficacy of a cognitive and behavioural intervention (CBT) for patients with recent onset, seropositive rheumatoid arthritis. Fifty‐three participants with a diagnosis of classical or definite rheumatoid arthritis, who were seropositive and had less than 2 years of disease history were recruited into the trial. All participants received routine medical management during the study, although half were randomly allocated to receive an adjunctive psychological intervention. All pre‐ and post‐treatment assessments were conducted blind to the allocation. Analyses were conducted of treatment completers and also by intention‐to‐treat. Significant differences were found between the groups at both post‐treatment and 6‐month follow‐up in depressive symptoms. While the CBT group showed a reduction in depressive symptoms, the same symptoms increased in the Standard group. At outcome but not follow‐up, the CBT group also showed reduction in C‐reactive protein levels. However, the CBT group did show significant improvement in joint involvement at 6‐month follow‐up compared with the Standard group, indicating physical improvements above those achieved with standard care. These results indicate that cognitive‐behavioural intervention offered as an adjunct to standard clinical management early in the course of RA is efficacious in producing reductions in both psychological and physical morbidity

Five-year followup of a cognitive–behavioral intervention for patients with recently-diagnosed rheumatoid arthritis: Effects on health care utilization†

OBJECTIVE To investigate whether cognitive-behavioral therapy (CBT) administered early in the course of rheumatoid arthritis (RA) has long-term effects on health care use. METHODS We reviewed the files of 47 of the original 53 patients with early RA who volunteered for a randomized controlled trial comparing CBT with no psychological intervention. Occasions of service provision associated with RA were documented and health care use was compared between groups. RESULTS The CBT group used fewer health care resources than the control group in the 5 years following intervention. Significant differences were observed for the number of inpatient nights, physiotherapy referrals, injections, and for total health care use. There was a trend that closely approached significance toward fewer episodes of surgery and orthopedic referrals in the CBT group. CONCLUSION These results suggest that CBT administered early in the course of RA can reduce health care use for the first 5 years after treatment. This is a stringent test of the efficacy of a brief psychological intervention, and supports the fact that brief psychological treatments can have long-term effects.

Psychological Well-Being in Rheumatoid Arthritis: Relationship to ‘Disease’ Variables and Affective Disturbance

Background: Resilience is likely to be important in understanding psychological responses to chronic physical illnesses. This study aimed to examine one measure of resilience – Ryff’s operationalized measure of psychological well-being (PWB) – in rheumatoid arthritis. It was hypothesized that PWB would be influenced by age and gender in the same way as in community samples, and that the absence of current mood disorder would be associated with high PWB. Methods: Rheumatology clinic outpatients (n = 104) were assessed for pain, disease activity, disability, depression and anxiety. PWB was assessed using Ryff’s six-subscale model. The measured variables were used in a logistic regression analysis to model the absence of clinically important mood disorder. Results: The expected variations in PWB according to age and gender were largely absent, with the overall findings suggesting that chronic illness in general, rather than arthritis in particular, affects PWB. Significant bivariate correlations were found between depression and pain, disease activity, disability and all six PWB subscales. However, in the regression analysis, only the PWB environmental mastery subscale and self-rated disability made significant contributions to the absence of mood disturbance, and their inclusion in the regression model correctly classified 81% of the total sample. Conclusions: These results require replication in a longitudinal study, but indicate the potential value of using PWB among people with rheumatoid arthritis to screen for individuals who may be particularly vulnerable to developing depression. It might be appropriate to target such people with focused psychological interventions.

Sustained response to tocilizumab, anti-IL-6 antibody, following anti-TNF-α failure in a patient with relapsing polychondritis complicated by aortitis

Kerr Brogan, Despina Eleftheriou, Kaukab Rajput, Clive Edelsten, Neil J. Sebire and Paul A. Brogan Paediatric Rheumatology Department, Great Ormond Street Hospital and Institute of Child Health, Audiology Department, Ophthalmology Department and Histopathology Department, Great Ormond Street Hospital, London, UK. Accepted 25 November 2011 Correspondence to: Despina Eleftheriou, Department of Rheumatology, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK. E-mail: d.eleftheriou@ich.ucl.ac.uk

Testing for the Integrity of Blinding in Clinical Trials: How Valid Are Forced Choice Paradigms?

Background: In randomised controlled trials, an increasingly used test of the ‘blindness’ of assessors is to have them guess the group to which each participant has been allocated. Because assessors are usually aware of the trial hypotheses, we predicted that trial participants who showed the greatest improvement would be assumed by an assessor to have been in the ‘preferred intervention’ group. Methods: Data were derived from a trial in recent-onset rheumatoid arthritis comparing cognitive behavioural therapy plus routine care with routine care alone. Results: Although in this trial assessor blindness was demonstrated, patients ‘guessed’ by the assessor to be in the cognitive therapy group showed significantly greater improvements than those predicted to have received routine care alone in variables predicted to change in the study protocol. Conclusions: These results indicate that even if an assessor’s guesses about patient group allocations are more accurate than expected by chance, this would not necessarily demonstrate failure of blinding. This casts further doubt on the validity of forced choice paradigms in testing the integrity of blinding in clinical trials.

THE ROLE OF COGNITIVE BEHAVIOURAL THERAPY IN FACILITATING ADAPTATION TO ILLNESS IN RHEUMATOID ARTHRITIS: A CASE SERIES

A considerable literature has developed over the past two decades that has investigated the utility of cognitive behavioural treatments for a variety of medical disorders, including rheumatoid arthritis. Research has consistently found that psychological variables affect the course of the illness and that cognitive behavioural approaches can improve psychological and physical function. However, the literature has focused almost exclusively on chronic illness. There is little literature that has investigated the role of cognitive behavioural therapy in facilitating the adjustment early in the disease course to diagnosis and subsequent illness. The diagnosis of any potentially chronic illness has enormous ramifications for a persons life and it is well documented that many people become depressed even early in the disease course. Theoretical accounts have been put forward that allow a model for understanding the process of adaptation and offer a foundation for the use of cognitive and behavioural strategies with a recently diagnosed group of patients. The present paper reports the use of a cognitive and behavioural intervention to facilitate coping and adjustment to illness.